Basic Information
Provider Information | |||||||||
NPI: | 1720566508 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PINNACLE HEALTH MEDICAL SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UPMC PINNACLE SOUTH HANOVER PRIMARY CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 409 S 2ND ST STE 2F | ||||||||
Address2: |   | ||||||||
City: | HARRISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 171041612 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172318929 | ||||||||
FaxNumber: | 7172215673 | ||||||||
Practice Location | |||||||||
Address1: | 1404 BALTIMORE ST STE 4 | ||||||||
Address2: |   | ||||||||
City: | HANOVER | ||||||||
State: | PA | ||||||||
PostalCode: | 173318698 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7176370470 | ||||||||
FaxNumber: | 7176374987 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2018 | ||||||||
LastUpdateDate: | 09/10/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARKLEY | ||||||||
AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VP | ||||||||
AuthorizedOfficialTelephone: | 7172318210 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.